Preservation of hepatic branch of the vagus nerve reduces the risk of gallstone formation after gastrectomy

Preservation of the celiac branch of the vagus nerve reduces the incidence of postoperative diarrhea in gastric cancer: a cohort study

BACKGROUND

To investigate the short-term and long-term outcomes of preserving the celiac branch of the vagus nerve during laparoscopic distal gastrectomy.

METHODS

A total of 149 patients with prospective diagnosis of gastric cancer who underwent laparoscopic-assisted distal gastrectomy (LADG) combined with Billroth-II anastomosis and D2 lymph node dissection between 2017 and 2018 were retrospectively analyzed. The patients were divided into the preserved LADG group (P-LADG, n = 56) and the resected LADG group (R-LADG, n = 93) according to whether the vagus nerve celiac branch was preserved. We selected 56 patients (P-LADG, n = 56) with preservation of the celiac branch of the vagus nerve and 56 patients (R-LADG, n = 56) with removal of the celiac branch of the vagus nerve by propensity-matched score method. Postoperative nutritional status, weight change, short-term and long-term postoperative complications, and gallstone formation were evaluated in both groups at 5 years of postoperative follow-up. The status of residual gastritis and bile reflux was assessed endoscopically at 12 months postoperatively.

RESULTS

The incidence of diarrhea at 5 years postoperatively was lower in the P-LADG group than in the R-LADG group (p < 0.05). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 3.389, 95% confidential interval = 1.143-10.049, p = 0.028). In the multivariate logistic analysis, the removal of vagus nerve celiac branch was an independent risk factor for the occurrence of postoperative diarrhea (odds ratio = 4.371, 95% confidential interval = 1.418-13.479, p = 0.010).

CONCLUSIONS

Preservation of the celiac branch of the vagus nerve in LADG reduced the incidence of postoperative diarrhea postoperatively in gastric cancer.

TRIAL REGISTRATION

This study was registered with the Ethics Committee of the First Affiliated Hospital of Dalian Medical University in 2014 under the registration number: LCKY2014-04(X).

High incidence of gallstones after Roux-en-Y reconstruction gastrectomy in gastric cancer: a multicenter, long-term cohort study

BACKGROUND

Roux-en-Y reconstruction is a common anastomosis technique during gastrectomy in gastric cancer. There is a lack of studies on gallstones after Roux-en-Y reconstruction gastrectomy. This study investigated the incidence and potential risk factors associated with gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer.

METHODS

The study analyzed data from gastric cancer who underwent radical gastrectomy and Roux-en-Y reconstruction at two hospitals between January 2014 and December 2020. The patients fall into distal and total gastrectomy groups based on the extent of gastrectomy. The cumulative event probability curve was plotted using the Kaplan-Meier, and differences in gallstone between groups were evaluated using the Log-Rank. Propensity score matching was applied to construct a balanced total versus distal gastrectomies cohort. A Cox regression was employed to analyze the risk factors for gallstones after Roux-en-Y reconstructive gastrectomy in gastric cancer. Further subgroup analysis was performed.

RESULTS

Five hundred thirty-one patients were included in this study, 201 in the distal gastrectomy group and 330 in the total gastrectomy. During the follow-up, gallstones occurred in 170 cases after gastrectomy, of which 145 cases accounted for 85.29% of all stones in the first two years after surgery. Then, to reduce the impact of bias, a 1:1 propensity score matching analysis was performed on the two groups of patients. A total of 344 patients were evaluated, with each subgroup comprising 172 patients. In the matched population, the Cox regression analysis revealed that females, BMI ≥23 kg/m 2 , total gastrectomy, No.12 lymph node dissection, and adjuvant chemotherapy were risk factors for gallstones after Roux-en-Y reconstructive gastrectomy. Subgroup analysis showed that open surgery further increased the risk of gallstones after total gastrectomy.

CONCLUSION

The incidence of gallstones increased significantly within 2years after Roux-en-Y reconstructive gastrectomy for gastric cancer. Patients with these risk factors should be followed closely after gastrectomy to avoid symptomatic gallstones.

Vagus innervation in the gastrointestinal tumor: Current understanding and challenges

The vagus nerve (VN) is the main parasympathetic nerve of the autonomic nervous system. It is widely distributed in the gastrointestinal tract and maintains gastrointestinal homeostasis with the sympathetic nerve under physiological conditions. The VN communicates with various components of the tumor microenvironment to positively and dynamically affect the progression of gastrointestinal tumors (GITs). The intervention in vagus innervation delays GIT progression. Developments in adeno-associated virus vectors, nanotechnology, and in vivo neurobiological techniques have enabled the creation of precisely regulated "tumor neurotherapies". Furthermore, the combination of neurobiological techniques and single cell sequencing may reveal more insights into VN and GIT. The present review aimed to summarize the mechanisms of communication between the VN and the gastrointestinal TME and to explore the potential and challenges of VN-based tumor neurotherapy in GITs.

A Gastrectomy for early-stage gastric cancer patients with or without preserving celiac branches of vagus nerves: A meta-analysis

BACKGROUND

Vagus nerve-preserving gastrectomy is increasingly popular in treating gastric cancer in the early stage, however the long and short-term outcomes after gastrectomy while preserving the celiac branch of the vagus nerve are not well defined. We aimed to summarize and compare perioperative and longer-term outcomes after celiac branch vagus nerve-preserving gastrectomy (CBP, preserving both the celiac and hepatic branches of the vagus nerve), compared to those without CBP (non-CBP, only the hepatic branch of the vagus nerve is preserved).

METHODS

We searched the Embase, PubMed, Cochrane Library and Web of Science databases for papers published before October 2021. The primary results were evaluated by short-term and long-term postoperative complications, whereas the secondary outcomes included surgery-related parameters, recovery-related parameters and overall survival. Random-effects or fixed-effects model were used to estimate odds ratio, and weighted mean difference for the outcomes. The underlying publication bias was identified via funnel charts, Begg's test and Egger's test. Sensitivity analysis was conducted by removing the research one by one.

RESULTS

A total of 9 studies consisting of 8 retrospective studies and one randomized control trial were included. The analysis included 1,109 patients, with 568 (51.2%) of patients receiving CBP and 541 (48.8%) patients who received non-CBP. The CBP group had a shorter time in terms of first flatus (weighted mean difference = -0.436, 95% confidence interval: -0.603 to -0.269; P < 0.001) and hospital stay (weighted mean difference = -0.456, 95% confidence interval: -0.874 to -0.037, P = 0.033) than the non-CBP group, but the time to the start of oral intake was comparable between the groups. Regarding short-term complications and surgery-related parameters, between CBP and non-CBP, no evident differences were observed in pancreatic complications, anastomotic leakage, postoperative bleeding, operation time, blood loss or lymph nodes examined. In terms of long-term complications, the incidence of gallstones in CBP was lower than that in non-CBP (odds ratio = 0.582, 95% confidence interval: 0.356-0.953, P = 0.031), and the incidence of bile reflux in CBP was lower than that in non-CBP (odds ratio = 0.473, 95% confidence interval: 0.280-0.800, P = 0.005). However, the prevalence rates of diarrhea, early dumping syndrome, esophageal reflux, and delayed gastric emptying were comparable between CBP and non-CBP.

CONCLUSION

The present research showed that gastric cancer patients in the early stage under CBP were superior to those without CBP in terms of incidence of gallstones, bile reflux, time of first flatus and hospital stay. Furthermore, it is imperative to conduct randomized control studies with larger sample sizes to determine the oncological survival outcomes when preserving the celiac branch.

Korean Practice Guidelines for Gastric Cancer 2022: An Evidence-based, Multidisciplinary Approach

Gastric cancer is one of the most common cancers in Korea and the world. Since 2004, this is the 4th gastric cancer guideline published in Korea which is the revised version of previous evidence-based approach in 2018. Current guideline is a collaborative work of the interdisciplinary working group including experts in the field of gastric surgery, gastroenterology, endoscopy, medical oncology, abdominal radiology, pathology, nuclear medicine, radiation oncology and guideline development methodology. Total of 33 key questions were updated or proposed after a collaborative review by the working group and 40 statements were developed according to the systematic review using the MEDLINE, Embase, Cochrane Library and KoreaMed database. The level of evidence and the grading of recommendations were categorized according to the Grading of Recommendations, Assessment, Development and Evaluation proposition. Evidence level, benefit, harm, and clinical applicability was considered as the significant factors for recommendation. The working group reviewed recommendations and discussed for consensus. In the earlier part, general consideration discusses screening, diagnosis and staging of endoscopy, pathology, radiology, and nuclear medicine. Flowchart is depicted with statements which is supported by meta-analysis and references. Since clinical trial and systematic review was not suitable for postoperative oncologic and nutritional follow-up, working group agreed to conduct a nationwide survey investigating the clinical practice of all tertiary or general hospitals in Korea. The purpose of this survey was to provide baseline information on follow up. Herein we present a multidisciplinary-evidence based gastric cancer guideline.

Late complication after gastrectomy for clinical stage I cancer: supplementary analysis of JCOG0912

BACKGROUND

Late complications following gastric cancer surgery, including postgastrectomy syndromes, are complex problems requiring a solution. Reported risk factors for developing late complications include surgery-related factors, such as the surgical approach and the extent of resection and reconstruction. However, this has not been assessed in a prospective study with a large sample size. Therefore, this study aimed to evaluate associations between surgery-related factors and the development of late complications. Data from the JCOG0912 trial were used. It compared laparoscopy-assisted distal gastrectomy (LADG) to open distal gastrectomy (ODG) in clinical stage I gastric cancer patients.

METHODS

This study included 881/921 patients enrolled in the JCOG0912 trial. The incidence of late complications was compared between the ODG and the LADG arms. In addition, associations between surgery-related factors and the development of late complications were assessed by multivariable analyses using the proportional odds model to identify relevant risk factors.

RESULTS

There was no difference in the type or number of patients with late complications between the LADG and the ODG arms. The multivariable analysis for each late complication revealed that the Billroth-I reconstruction (vs. R-en-Y or Billroth-II) had a lower risk of cholecystitis [odds ratio (OR) 0.187, 95% confidence interval (CI) 0.039-0.905, P = 0.037] or ileus (OR 0.116, 95%CI 0.033-0.406, P < 0.001), and pylorus-preserving gastrectomy (vs. R-en-Y or Billroth-II) had a higher risk of reflux esophagitis (OR 3.348, 95% CI 1.371-8.176, P = 0.008). The surgical approach was not a risk factor for any late complications.

CONCLUSION

Differences in surgical approaches did not constitute a risk for developing late complications after gastrectomy. Billroth-I reconstruction reduced the risk of ileus and cholecystitis, but pylorus-preserving gastrectomy carried a risk for reflux esophagitis.

Prophylactic cholecystectomy: A valuable treatment strategy for cholecystolithiasis after gastric cancer surgery

The main treatment for gastric cancer is surgical excision. Gallstones are one of the common postoperative complications of gastric cancer. To avoid the adverse effects of gallstone formation after gastric cancer surgery, we reviewed the causes and risk factors and mechanisms involved in gallstone formation after gastric cancer surgery. The evidence and value regarding prophylactic cholecystectomy (PC) during gastric cancer surgery was also reviewed. Based on previous evidence, we summarized the mechanism and believe that injury or resection of the vagus nerve or changes in intestinal hormone secretion can lead to physiological dysfunction of the gallbladder and Oddi sphincter, and the lithogenic components in the bile are also changed, ultimately leading to CL. Previous studies also have identified many independent risk factors for CL after gastric cancer, such as type of gastrectomy, reconstruction of the digestive tract, degree of lymph node dissection, weight, liver function, sex, age, diabetes and gallbladder volume are closely related to CL development. At present, there are no uniform guidelines for the selection of treatment strategies. As a new treatment strategy, PC has undeniable advantages and is expected to become the standard treatment for CL after gastric cancer in the future. The individualized PC strategy for CL after gastric cancer is the main direction of future research.

Function-Preserving Gastrectomy for Early Gastric Cancer

Simple Summary

For patients with early gastric cancer (EGC), a good prognosis is achieved by conventional standard gastrectomy with radical lymphadenectomy. However, postgastrectomy syndrome is often inevitable and results in decreased quality of life (QOL). To improve patients’ QOL, proximal gastrectomy instead of total gastrectomy and pylorus-preserving gastrectomy instead of distal gastrectomy have been widely accepted as function-preserving gastrectomies. Recently, personalized, minimized gastrectomy with sentinel node navigation surgery has been developed and is expected to be an ideal treatment option for patients with EGC. Herein, we review the indications, surgical techniques, and postoperative outcomes of function-preserving gastrectomy.

Abstract

Recently, minimally invasive (endoscopic or laparoscopic) treatment for early gastric cancer (EGC) has been widely accepted. However, a standard gastrectomy with radical lymphadenectomy is generally performed in patients with EGC who have no indications for endoscopic resection, and postgastrectomy dysfunction is one of the problems of standard gastrectomy. Function-preserving gastrectomy, such as proximal gastrectomy and pylorus-preserving gastrectomy, can be considered when attempting to preserve the patient’s quality of life (QOL) postoperatively. In addition, sentinel node navigation surgery for EGC has been applied in clinical practice in several prospective studies on function-preserving personalized minimized gastrectomy. In the near future, the sentinel lymph node concept is expected to form the basis for establishing an ideal, personalized, minimally invasive function-preserving treatment for patients with EGC, which will improve their postoperative QOL without compromising their long-term survival. In this review article, we summarize the current status, surgical techniques, and postoperative outcomes of function-preserving gastrectomy for EGC.

A new technique for treating hiatal hernia with gastroesophageal reflux disease: the laparoscopic total left-side surgical approach

Introduction

Although the traditional bilateral surgical approach to treat hiatal hernia (HH) with gastroesophageal reflux disease (GERD) can provide local protection of the vagus nerve, the integrity of the entire vagus nerve cannot be evaluated. Therefore, we developed and described the total left-side surgical approach (TLSA), which theoretically reduces injury to the vagus nerve, and described the detailed surgical procedure.

Methods

Initially, we performed a cadaver study to explore the characteristics of the vagus nerve. Then, we prospectively evaluated the TLSA in 5 patients with HH and GERD between June 2020 and September 2020. Demographic characteristics, surgical parameters, perioperative outcomes, and follow-up findings were analyzed.

Results

The TLSA was successfully used in five patients (40–64 years old), and no major complications were noted. The median total operative time was 114 min, median blood loss was 50 mL, and median postoperative hospital stay was 3.8 days. Gastrointestinal function recovered within 4 days of surgery in all the patients. The 6-month follow-up gastroscopy examination showed well-established gastroesophageal flap valves. Compared with the baseline results, the 6-month follow-up results showed lower values for the total GerdQ score (12.4 vs. 6.2) and the total esophageal acid exposure time (3.48% vs. 0.38%). Based on the European Organization for Research and Treatment of Cancer quality of life questionnaire-stomach module 52 results, the incidence of dysphagia and flatulence decreased over time after the TLSA.

Conclusions

The TLSA provides a clear and broad surgical field, less trauma, and rapid recovery; moreover, it is technically simple. Although our results suggest that the TLSA provides safety and short-term efficacy and is feasible for patients with HH and GERD, long-term results from a larger clinical trial are needed to validate these findings.

Trial registration ChiCTR2000034028, registration date is June 21, 2020. The study was registered prospectively

Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial)

BACKGROUND

There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer.

METHODS

The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days.

RESULTS

Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups.

CONCLUSION

Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov).

The Effect of Minimally Invasive Gastrectomy for Gastric Cancer on Postoperative Gallstone Formation

BACKGROUND

Gallstones are known to occur quite frequently after gastrectomy. Most of the studies about postoperative cholelithiasis have focused on open gastrectomy, whereas laparoscopic gastrectomy has recently gained popularity as a type of minimally invasive surgery (MIS). Hence, the efficacy of MIS in preventing post-gastrectomy gallstone formation remains to be elucidated. This study aimed to evaluate the risk of gallstone formation after MIS for clinical stage I/IIA gastric cancer.

METHODS

A total of 1166 patients undergoing gastrectomy for clinical stage I/IIA gastric cancer between 2009 and 2016 were included in this study. Gallstones were detected on abdominal ultrasound and/or computed tomography. Multivariate logistic regression analysis was used to determine factors associated with postoperative gallstone formation.

RESULTS

Gallstone formation was observed in 174 patients (15%), of whom 22 (2%) experienced symptomatic cholelithiasis. In multivariate analysis, the following were identified as risk factors for post-gastrectomy gallstone formation: open approach with an odds ratio (OR) of 1.670 and a 95% confidence interval (CI) of 1.110-2.510 (P = 0.014), older age (OR 1.880; 95% CI 1.290-2.730; P < 0.001), high body mass index (OR 1.660; 95% CI 1.140-2.420; P = 0.008), Roux-en-Y (RY) reconstruction (OR 1.770; 95% CI 1.230-2.530; P = 0.002), hepatic branch vagotomy (OR 1.600; 95% CI 1.050-2.440; P = 0.029), and intra-abdominal infectious complications (OR 3.040; 95% CI 1.680-5.490; P < 0.001).

CONCLUSION

Our study suggested that MIS along with the preservation of the hepatic vagus nerve and non-RY reconstruction could help prevent post-gastrectomy gallstone development.

Current status of function-preserving gastrectomy for gastric cancer

Early gastric cancer (EGC) has excellent postoperative survival outcomes; thus, one of the recent keywords in the treatment of EGC is "function-preserving gastrectomy (FPG)." FPG reduces the extent of lymphadenectomy and gastric resection without compromising the long-term prognosis. Proximal gastrectomy (PG) is an alternative to total gastrectomy (TG) for EGC in the upper-third of the stomach, in which the gastric reservoir, gastric acid secretion, and intrinsic factors are maintained. Distal gastrectomy (DG) with a small remnant stomach, namely subtotal gastrectomy (STG), is another option for upper EGC, where the function of the cardia and fundus is preserved. Pylorus-preserving gastrectomy (PPG) is a good alternative to DG for EGC in the middle-third of the stomach, where pyloric function is preserved. Following elucidation of the markedly low incidences of possible metastasis to lymph node stations where dissection is omitted, the oncological safety of these FPG procedures was clarified. Nutritional advantages of PG or STG over TG have been reported; however, the standardized reconstruction methods after PG are yet to be established, and it is important to devise methods to prevent postoperative gastroesophageal reflux and anastomotic complications regardless of the reconstruction method. Nutritional benefits of PPG compared with DG have also been clarified, in which reducing postoperative gastric stasis is important. For the further spread of these FPG procedures, several issues, such as precise evaluation of preserved function, confirmation of oncological safety, and standardization of the technique, should be addressed in future prospective randomized controlled trials.